pancreatitis

2. THE PANCREAS
 The pancreas, located in the upper abdomen, has endocrine as well as
exocrine functions.
 The secretion of pancreatic enzymes into the gastrointestinal tract
through the pancreatic duct represents its exocrine function.
 The secretion of insulin, glucagon, and somatostatin directly into the
bloodstream represents its endocrine function.

3. The liver, biliary system, and pancreas.

4. Disorders of the Pancreas
 Pancreatitis (inflammation of the pancreas) is a serious disorder.
 The most basic classification system used to describe or categorize the
various stages and forms of pancreatitis divides the disorder into acute
or chronic forms.

5. ACUTE PANCREATITIS
 Acute pancreatitis ranges from a mild, self-limiting disorder to a
severe, rapidly fatal disease that does not respond to any treatment.
 Mild acute pancreatitis is characterized by edema and inflammation
confined to the pancreas.
 The milder form of pancreatitis, the patient is acutely ill and at risk for
hypovolemic shock, fluid and electrolyte disturbances, and sepsis.

6.  The tissue becomes necrotic, and the damage extends into the
retroperitoneal tissues.
 Local complications consist of pancreatic cysts or abscesses and acute
fluid collections in or near the pancreas.
 Systemic complications, such as acute respiratory distress syndrome,
shock, disseminated intravascular coagulopathy, and pleural effusion,
can increase the mortality rate to 50% or higher.

7.  Severe abdominal pain is the major symptom of pancreatitis that
causes the patient to seek medical care.
 Abdominal pain and tenderness and back pain result from irritation
and edema of the inflamed pancreas that stimulate the nerve endings.
 Increased tension on the pancreatic capsule and obstruction of the
pancreatic ducts also contribute to the pain.

8.  Typically, the pain occurs in the midepigastrium.
 Pain is frequently acute in onset, occurring 24 to 48 hours after a very
heavy meal or alcohol ingestion, and it may be diffuse and difficult to
localize.
 It is generally more severe after meals and is unrelieved by antacids.
Pain may be accompanied by abdominal distention; a poorly defined,
palpable abdominal mass; and decreased peristalsis.
 Pain caused by pancreatitis is accompanied frequently by vomiting
that does not relieve the pain or nausea.

9.  The patient appears acutely ill.
 Abdominal guarding is present.
 The abdomen may remain soft in the absence of peritonitis.
 Ecchymosis (bruising) in the flank or around the umbilicus may
indicate severe pancreatitis.
 Nausea and vomiting are common in acute pancreatitis.
 The emesis is usually gastric in origin but may also be bile-stained.
 Fever, jaundice, mental confusion, and agitation also may occur.

10.  Hypotension is typical and reflects hypovolemia and shock caused by
the loss of large amounts of protein-rich fluid into the tissues and
peritoneal cavity.
 The patient may develop tachycardia, cyanosis, and cold, clammy skin
in addition to hypotension.
 Acute renal failure is common.

11.  Respiratory distress and hypoxia are common, and the patient may
develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and
abnormal blood gas values.
 Myocardial depression, hypocalcemia, hyperglycemia, and
disseminated intravascular coagulopathy (DIC) may also occur with
acute pancreatitis.

12. Assessment and Diagnostic Findings
 The diagnosis of acute pancreatitis is based on a history of abdominal
pain, the presence of known risk factors, physical examination
findings, and diagnostic findings.
 Serum amylase and lipase levels are used in making the diagnosis of
acute pancreatitis.

13.  In 90% of the cases, serum amylase and lipase levels usually rise in
excess of three times their normal upper limit within 24 hours.
 Serum amylase usually returns to normal within 48 to 72 hours.
 Serum lipase levels may remain elevated for 7 to 14 days.
 Urinary amylase levels also become elevated and remain elevated
longer than serum amylase levels.
 The white blood cell count is usually elevated; hypocalcemia is present
in many patients and correlates well with the severity of pancreatitis.

14.  Transient hyperglycemia and glucosuria and elevated serum bilirubin
levels occur in some patients with acute pancreatitis.
 X-ray studies of the abdomen and chest may be obtained to
differentiate pancreatitis from other disorders that may cause similar
symptoms and to detect pleural effusions.
 Ultrasound and contrast-enhanced computed tomography scans are
used to identify an increase in the diameter of the pancreas and to
detect pancreatic cysts, abscesses, or pseudocysts.

15.  Hematocrit and hemoglobin levels are used to monitor the patient for
bleeding.
 Peritoneal fluid, obtained through paracentesis or peritoneal lavage,
may contain increased levels of pancreatic enzymes.
 The stools of patients with pancreatic disease are often bulky, pale, and
foul-smelling. Fat content of stools varies between 50% and 90% in
pancreatic disease;

16.  Endoscopic retrograde cholangio pancreatography (ERCP)is rarely
used in the diagnostic evaluation of acute pancreatitis because the
patient is acutely ill; however, it may be valuable in the treatment of
gallstone pancreatitis.

17. Medical Management
 Management of the patient with acute pancreatitis is directed toward
relieving symptoms and preventing or treating complications.
 All oral intake is withheld to inhibit pancreatic stimulation and
secretion of pancreatic enzymes.
 Parenteral nutrition is usually an important part of therapy,
particularly in debilitated patients, because of the extreme metabolic
stress associated with acute pancreatitis.

18.  Nasogastric suction may be used to relieve nausea and vomiting, to
decrease painful abdominal distention and paralytic ileus, and to
remove hydrochloric acid so that it does not enter the duodenum and
stimulate the pancreas.
 Histamine-2 (H2) antagonists (eg, cimetidine [Tagamet] and ranitidine
[Zantac]) may be prescribed to decrease pancreatic activity by
inhibiting HCl secretion.

19. PAIN MANAGEMENT
 Adequate pain medication is essential during the course of acute
pancreatitis to provide sufficient pain relief and minimize restlessness,
which may stimulate pancreatic secretion further.
 Morphine and morphine derivatives are often avoided because it has
been thought that they cause spasm of the sphincter of Oddi;
meperidine (Demerol) is often prescribed because it is less likely to
cause spasm of the sphincter.
 Antiemetic agents may be prescribed to prevent vomiting.

20. INTENSIVE CARE
 Correction of fluid and blood loss and low albumin levels is necessary
to maintain fluid volume and prevent renal failure.
 The patient is usually acutely ill and is monitored in the intensive care
unit, where hemodynamic monitoring and arterial blood gas
monitoring are initiated.
 Antibiotic agents may be prescribed if infection is present; insulin may
be required if significant hyperglycemia occurs.

21. RESPIRATORY CARE
 Aggressive respiratory care is indicated because of the high risk for
elevation of the diaphragm, pulmonary infiltrates and effusion, and
atelectasis.
 Hypoxemia occurs in a significant number of patients with acute
pancreatitis even with normal x-ray findings.
 Respiratory care may range from close monitoring of arterial blood
gases to use of humidified oxygen to intubation and mechanical
ventilation.

22. BILIARY DRAINAGE
 Placement of biliary drains (for external drainage) and stents
(indwelling tubes) in the pancreatic duct through endoscopy has been
performed to reestablish drainage of the pancreas.
 This has resulted in decreased pain and increased weight gain.

23. SURGICAL INTERVENTION
 Although often risky because the acutely ill patient is a poor surgical
risk, surgery may be performed to assist in the diagnosis of
pancreatitis (diagnostic laparotomy), to establish pancreatic drainage,
or to resect or debride a necrotic pancreas.
 The patient who undergoes pancreatic surgery may have multiple
drains in place postoperatively as well as a surgical incision that is left
open for irrigation and repacking every 2 to 3 days to remove necrotic
debris.

24. Multiple sump tubes are used
after pancreatic surgery.
Triple-lumen tubes consist of
ports that provide tubing for
irrigation, air venting, and
drainage.

25. POSTACUTE MANAGEMENT
 Antacids may be used when acute pancreatitis begins to resolve.
 Oral feedings low in fat and protein are initiated gradually.
 Caffeine and alcohol are eliminated from the diet.
 If the episode of pancreatitis occurred during treatment with thiazide
diuretics, corticosteroids, or oral contraceptives, these medications are
discontinued.

26.  Follow-up of the patient may include ultrasound, x-ray studies, or
ERCP to determine whether the pancreatitis is resolving and to assess
for abscesses and pseudocysts.
 ERCP may also be used to identify the cause of acute pancreatitis if it is
in question and for endoscopic sphincterotomy and removal of
gallstones from the common bile duct.
 Thanking you.